Gearing up for the Travel Season: How Clinicians Can Ensure Their Patients are Packed with Knowledge on Zika Prevention

Moderator: Marcia Friedman

Presenters: Mary Tanner, MD, FAAP; Allison Taylor Walker PhD, MPH

Date/Time: December 8, 2016, 2:00 - 3:00 pm ET

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Coordinator: Welcome and thank you for standing by. At this time, all participants will be on listen-only until the question and answer session of today’s conference. At which time you may press star 1 to ask a question. Today’s conference is being recorded. If you have any objections, please disconnect at this time. I’d now like to turn the meeting over to your host, Ms. Marcia Friedman. Ma’am, you may begin.

Marcia Friedman: Thank you, (Amber). Good afternoon. I am Marcy Friedman and I’m representing the Clinical Outreach and Communication Activity, COCA, with the Emergency Risk Communication Branch at the Centers for Disease Control and Prevention. I’m happy to welcome you to today’s COCA call, Gearing up for the Travel Season:. How Clinicians Can Ensure Their Patients are Packed with Knowledge on Zika Prevention. You may participate in today’s presentation by audio only, via webinar, or you may download the slides if you are unable to access the webinar. The PowerPoint slide set and the webinar link can be found on our COCA webpage at emergency.cdc.gov/coca. Free continuing education is offered for this COCA Call. Instructions on how to earn continuing education will be provided at the end of the call.

CDC, our planners, presenters, and their spouses and partners wish to disclose they have no financial interest or other relationships with the manufacturers of commercial products, suppliers of commercial services or commercial supporters. Planners have reviewed content to ensure that there is no bias. This presentation will not include any discussion of the unlabeled use of a product or products under investigational use.

At the end of the presentation, you will have the opportunity to ask the presenters questions. On the phone, dialing Star 1 will put you in the queue for your question. You may also submit questions through the webinar system at any time during the presentation by selecting the Q&A tab at the top of the webinar screen and typing in your question. Questions are limited to clinicians who would like information related to Zika virus infection. For those who have media questions, please contact CDC Media Relations at 404-639-3286 or send an email to media@cdc.gov. If you are a patient, please refer your questions to your healthcare provider.

At the conclusion of today’s session, the participant will be able to describe the latest guidance for travelers visiting areas with active Zika transmission and differentiate between countries with epidemic and endemic Zika; advise patients who are considering or traveling to—considering or planning travel on the possible Zika risk associated with their travel and the protective measures they can take before, during and after their trip. Also, at the end of today’s session, participants will be able to apply CDC Zika laboratory testing algorithms when determining which patients with relevant travel history, possible Zika virus exposure, or Zika symptoms, should receive testing. And also, state recommendations for travelers returning from areas with active Zika transmission to prevent further transmission of Zika.

Today’s first presenter is Dr. Mary Tanner. Dr. Tanner is an Epidemic Intelligence Service officer in the Division of HIV/AIDS Prevention in the National Center for [HIV/AIDS, Viral Hepatitis, STD, and TB Prevention] at the CDC. She earned her Doctorate of Medicine from the University of Missouri, Columbia; completed fellowship training in pediatric infectious diseases at St. Jude’s Children’s Research Hospital in Memphis, Tennessee; and completed a general pediatric residency at Children’s Mercy Hospital and Clinics in Kansas City, Missouri. Dr. Tanner is board certified in pediatrics.

Our second presenter is Dr. Allison Taylor Walker. Dr. Walker attended Northwestern University, completed a master of public health degree at Emory University and has PhD in global disease epidemiology and control from Johns Hopkins University. She joined the CDC in 2005, and she has worked on almost all continents for global health programs here at CDC. Her work includes serving as CDC’s subject matter expert for polio eradication in the Horn of Africa, conducting research in the field of global multidrug-resistant tuberculosis, studying the transmission of and response to global water borne disease and serving as the epidemiology team lead for the Travelers’ Health Task Force for the Zika response. Allison is currently a senior epidemiologist on the Surveillance and Epidemiology team in the Traveler’s Health Branch.

At this time, please welcome Dr. Tanner.

Dr. Mary Tanner: Hi, my name is Mary Tanner. I’m an Epidemic Intelligence Service officer with the CDC, and I’ve worked with the CDC’s Zika Virus Response in the Emergency Operations Center or EOC. My part of today’s presentation will focus on issues related to Zika virus and pregnancy. The objectives include reviewing pre-travel counseling recommendations for men and women of reproductive age, pregnant women, and women considering pregnancy who are planning travel to areas with active Zika virus transmission; discussing recommended protective measures for women who live in or travel to areas with active Zika virus transmission; and describing the current guidance regarding the care of pregnant women who have possible Zika virus exposure.

Let’s take a moment to appreciate why the current Zika virus epidemic represents a unique challenge. The last time an infectious pathogen, rubella virus, caused an epidemic of congenital defects was more than 50 years ago, before an effective vaccine became available. Although Zika virus was first identified almost 70 years ago, its potentially devastating effects on fetal development have been identified only recently.

In response to this emerging public health threat, CDC activated the EOC on January 22 to help coordinate the public health response. The EOC was initially activated as a Level 3 response. In this level of response CDC experts in a particular disease lead the work with assistance from EOC staff. On February 8, CDC elevated its EOC activation to Level 1, the highest level of response. This is reserved for critical emergencies requiring a large number of staff to work 24-hours a day, seven days a week. Prior to the Zika virus response, the only Level 1 activations in CDC history were for Hurricane Katrina, HIN1, and Ebola.

Before 2015, Zika virus disease was found in areas of Africa, Southeast Asia, and the Pacific Islands. Currently, outbreaks are occurring in most countries or territories in the Americas, including the Commonwealth of Puerto Rico, the U.S. Virgin Islands, and Miami-Dade County, Florida, in the continental U.S. Outbreaks are also occurring in areas of Asia and the Pacific Islands. Even though whole countries are shaded, this does not mean that there’s active Zika virus transmission occurring everywhere in the country. You can find the list of countries with current active transmission on CDC’s Zika virus website.

One of the top priorities of this public health response is protecting pregnant women and their fetuses from the serious adverse outcomes that have been associated with Zika virus infection during pregnancy. When the Zika virus response first started, there were many unknowns. Since then, we’ve learned that pregnant women can be infected through the bite of an infected mosquito or through sex without a condom with an infected partner. If a woman is infected during pregnancy, Zika virus can be passed to her fetus during pregnancy or around the time of birth. If a woman is infected with Zika virus around the time of conception, the risk to the fetus is currently unknown. However, maternal infection with other viruses around the time of conception have been associated with congenital infection and adverse pregnancy outcomes.

We’ve also learned more about the effects of Zika virus infection during pregnancy. CDC has conducted a systematic evaluation of the evidence related to Zika virus infection and congenital anomalies. On April 13, the investigating team concluded that a causal relationship exists between prenatal Zika virus infection and microcephaly and other serious congenital brain anomalies.

On November 3, JAMA Pediatrics published an article describing the congenital Zika syndrome as a recognizable pattern of anomalies associated with the Zika virus infection during pregnancy. Although many components of this syndrome, like cognitive, sensory and motor disabilities, are similar to other congenital infections, there are five characteristic findings that are either not seen or occur rarely with other infections during pregnancy. These include severe microcephaly with partially collapsed skill, thin cerebral cortices with subcortical calcifications, macular scarring and focal pigmentary retinal mottling, congenital contractures, and early hypertonia with symptoms of extrapyramidal involvement. Congenital Zika infection has also been linked to hearing loss and other neurologic sequelae.

Not all infants affected by congenital Zika virus infection will manifest the five characteristic anomalies described on the last slide. We’re still learning more about the full spectrum of adverse reproductive outcomes caused by Zika virus infection. A recent report in the MMWR clarified that some infants affected by congenital Zika virus infection do not have visible microcephaly at birth. This case series describes 13 infants with laboratory evidence of congenital Zika virus infections and no microcephaly at birth who were subsequently found to have brain anomalies. Some of these infants had other structural or functional abnormalities noted at birth. This case series further illustrates that congenital Zika infection can produce a variety of clinical presentations in affected infants.

Understanding some of the potential adverse effects associated with Zika virus infection during pregnancy underscores the public health importance of the Zika virus response. Protecting pregnant women and their fetuses is the major driver of much of the guidance we’ll discuss during the rest of this talk. In this section on prevention, I’ll review pre-travel counseling recommendations and discuss recommended protective measures for women who live in or travel to areas with active Zika virus transmission.

CDC recommends that pregnant women not travel to areas with active Zika virus transmission. If a pregnant woman must travel to an area of active transmission, she should talk to her healthcare provider before departing and strictly follow steps to avoid mosquito bites and prevent sexual transmission of Zika virus during her trip. Pregnant women considering travel should be encouraged to review the updated information on CDC’s Zika virus website.

To prevent mosquito bites while traveling, pregnant women should wear long sleeve shirts and long pants; stay and sleep in places with air conditioning or that use window and door screens to keep mosquitoes outside; and use EPA registered insect repellant.

For couples with a partner who lives in or has traveled to an area with active Zika virus transmission, couples in which a woman is pregnant should use condoms consistently and correctly every time they have sex or abstain from sex; not share sex toys; and couples should follow these precautions for the duration of the pregnancy even if the pregnant woman’s partner does not have symptoms or feel sick.

Before a woman or her partner plan travel, they should talk to their doctor or other healthcare provider about their plans to become pregnant and the risk of Zika virus infection. If a woman and/or her partner travel to an area with active transmission, they should strictly follow steps to prevent mosquito bites during the trip, and they should be aware of preconception guidance related to Zika virus exposure.

In September, CDC updated the guidance related to preconception counseling and prevention of sexual transmission of Zika virus. This guidance was created to help healthcare providers discuss pregnancy planning with women and their partners after possible Zika virus exposure. The table on this slide shows the suggested timeframes for waiting to conceive. Women should wait at least eight weeks after symptoms start or the last possible exposure. Men should wait at least 6 months after symptoms start or after the last possible exposure. Given that limited data are available, some couples in which a partner had possible Zika virus exposure might choose to wait longer or shorter than the recommended period to conceive, depending on individual circumstances and risk tolerance.

CDC has produced a guide for counseling women and men of reproductive age who are considering travel to areas with active Zika virus transmission. The guide includes recommendations from CDC’s interim guidance, and talking points to cover while discussing recommendations. It’s available on CDC’s Zika virus website.

CDC has also developed a guide to assist with counseling individuals living in areas with Zika virus transmission who want to become pregnant and who have not experienced clinical illness consistent with Zika virus disease. This material includes recommendations from CDC’s updated guidance, key questions to ask patients, and sample scripts for discussing recommendations. The guide is also available on the Zika virus website.

Preventing unintended pregnancy among people who may be exposed to Zika virus is a primary strategy to reduce the number of pregnancies affected by Zika virus infections. The best way for sexually active women and their partners to reduce the risk of untended pregnancy is to use effective birth control consistently and correctly. It’s important for women and their partners to find a type of birth control that is safe and effective and meets their lifestyle needs and preferences. The CDC’s Zika virus website includes additional information about preventing unintended pregnancy, including a chart that outlines different forms of birth control and their effectiveness, which is partially shown here.

Now that we’ve discussed prevention efforts, I’ll review CDC’s current guidance related to caring for pregnant women with possible Zika virus exposure.

All pregnant women should be assessed for possible Zika virus exposure and signs or symptoms of infection at each prenatal care visit. The most common symptoms of Zika virus infection are fever, rash, joint pain, and conjunctivitis. Women should be asked if they traveled to or live in an area with active Zika virus transmission during their pregnancy or periconceptional period. The periconceptional period is defined as the 6 weeks prior to the last menstrual period or 8 weeks prior to conception. It should be asked if they had sex without a condom with a partner who has traveled to or lives in an area with Zika virus transmission.

To assist with the assessment process, CDC has created a tool to screen pregnant women for exposure to Zika virus and for signs and symptoms of Zika virus disease to determine whether testing is indicated. This tool is located on the CDC’s Zika virus website.

Anyone who has or recently had symptoms of Zika virus infection and lives in or recently traveled to an area with Zika virus or had sex without a condom with a partner who lived in or traveled to an area with Zika virus should be tested. Additionally, all pregnant women who live in or recently traveled to an area with active Zika virus transmission or had sex without a condom with a partner who lives in or travelled to an area with active Zika virus transmission should be tested whether or not they have symptoms of infection.

Diagnostic testing for Zika virus infection can be accomplished using both molecular and serologic methods. Real-time reverse transcriptase-polymerase chain reaction or rRT-PCR is the molecular test. It can detect viral RNA in body fluids like serum or in tissues like placentas. Any time RNA is detected, it provides a definitive diagnosis of recent Zika virus infection. Serologic tests include the Zika virus immunoglobulin M or IgM enzyme-linked immunosorbent assay. This assay detects anti-Zika virus IgM antibodies in serum or CSF. Presumed positive, equivocal, or inconclusive Zika virus IgM tests can be further evaluated by plaque-reduction neutralization testing or PRNTs.

PRNTs evaluate neutralizing antibodies in the serum. Neutralizing antibodies to Zika virus develop shortly after IgM antibodies and consist primarily of IgG antibodies. Zika virus is a flavivirus, which is closely related to dengue, yellow fever, Japanese encephalitis, and West Nile viruses. After someone is infected with a flavivirus, their neutralizing antibodies are expected to persist for many years and are believed to confer prolonged immunity.

The different Zika virus tests available have different limitations. First, with regard to molecular testing, the presence of Zika virus RNA in body fluids is relatively short lived, and the duration of time it is detectable can vary based on different factors. Therefore, a negative molecular test result cannot completely exclude the possibility of infection. Second, testing for Zika virus IgM can produce false positive results because of cross-reacting antibodies against related flaviviruses or due to nonspecific reactivity. Third, PRNTs may not be able to distinguish the infecting virus in people previously infected with or vaccinated against a related flavivirus. When a person previously infected with or vaccinated against a flavivirus is exposed to a related flavivirus, there can be a rapid rise in neutralizing antibodies against multiple flaviviruses making it difficult to determine which specific virus is responsible for the recent infection.

Because of the different limitations of the various Zika virus tests, the approach to testing varies based on different clinical factors. This flowchart, which is available on CDC’s Zika virus website, outlines CDC’s current testing and interpretation recommendations for pregnant women with possible exposure to Zika virus. The two main pathways in the flowchart, designated by the letters A and B, differ based on the timing of the patient’s infection or exposure.

Testing Pathway A is for symptomatic women presenting less than 2 weeks after symptom onset, or for asymptomatic women who do not live in an area with active Zika virus transmission who present less than 2 weeks after possible exposure. For these women, the first step of testing is Zika virus rRT-PCR on serum and urine.

Testing Pathway B is for three different categories: 1) Symptomatic pregnant women who present 2 to 12 weeks after symptom onset, 2) asymptomatic women not living in an area with active Zika virus transmission who present 2 to 12 weeks after possible exposure, and 3) asymptomatic women in their first or second trimester who live in areas with active Zika virus transmission. For these women, the recommended first step of testing is Zika and dengue virus IgM antibody testing.

Once you’ve determined the appropriate pathway of the flowchart and the initial step in testing, the additional steps of testing and interpretation can be easily followed from there. The testing flowchart on CDC’s Zika virus website also includes a chart detailing management recommendations based on the different testing outcomes. I will not review these management recommendations today, but do keep in mind that it may be useful to consider referral to a specialist with expertise in pregnancy management for women who have test results indicative of recent Zika virus infections or recent flavivirus infection.

To assist with managing all this information, CDC has developed an interactive web algorithm. This web tool is intended to help healthcare providers apply the updated recommendations for Zika virus testing, interpretation of results, and clinical management for pregnant women with possible exposure to Zika virus. The program can be accessed at CDC’s Zika virus website.

The detailed guidance that we’ve gone through regarding caring for pregnant women with possible Zika virus exposure, highlights how much we have already learned about this virus and its effects. However, there’s still a lot more to learn, and more work will need to be done in the public health response to Zika virus. At this point, I’ll briefly highlight some of CDC’s current work in this area.

Although we’ve learned a lot about the association between Zika virus and certain pregnancy outcomes, many questions still remain. For example, what is the level of risk from a Zika virus infection during pregnancy? In other words, if a woman is infected, what’s the chance her fetus will have Zika-associated problems? When during pregnancy does Zika virus infection pose the highest risk to the fetus? What is the full range of potential health problems that Zika virus infection can cause? I spoke earlier about the congenital Zika syndrome, but affected infants may have a range of other presentations. We’re working to determine the full range of potential health problems that Zika virus infection may cause. What other factors, such as other infections occurring at the same time, might affect the risk for birth defects?

Answering these and other critical questions is a focus of our ongoing research. Understanding more about this virus and its effects, may help improve prevention efforts and ultimately reduce the negative impact of Zika virus infection during pregnancy. CDC and the Pregnancy and Birth Defects Task Force within CDC’s Zika Virus Response are actively engaged in ongoing efforts to learn more about Zika virus infection during pregnancy. Some of these activities include surveillance of pregnant women, fetuses, and infants affected by Zika virus. These efforts allow the CDC to monitor the impact of Zika virus in the United States, DC, and US territories, while collecting data that can be used to drive effective public health action. More information about these activities is available on CDC’s Zika virus website.

It’s important to remember that much of this critical work is dependent on reports from healthcare providers. Healthcare providers should inform their health departments of any non-negative Zika virus testing results, in accordance with applicable state, tribal, local and territorial laws.

The CDC has also developed many useful clinical support tools and patient communication resources for healthcare providers and their patients. These are available on CDC’s Zika virus website and most are available in multiple languages.

In closing, I wanted to again emphasize that Zika virus disease is a challenging emerging public health issue, which includes special concerns for pregnant women and their fetuses and infants. It’s been a privilege and an honor to have had the opportunity to work with so many committed individuals and their partners on this response. Thank you, and I think we will move on to Dr. Walker’s portion of the presentation.

Dr. Allison Taylor Walker: Good afternoon and thank you Dr. Tanner. Zika virus is a single-stranded RNA virus and genus Flavivirus in the family Flaviviridae. It’s closely related to dengue virus, yellow fever, Japanese encephalitis, and West Nile virus. Most of the transmission includes vector-borne or a bite from an infected Aedes mosquito, primarily Aedes aegypti but also Aedes albopictus in the Americas. They can be intrauterine and perinatal transmission of Zika virus and sexual transmission can occur from any infected partners. The virus can spread during symptoms, before symptoms start, and after symptoms resolve. Zika can be transmitted through laboratory exposure, and finally, it’s probable that Zika virus can be transmitted through blood transfusions via platelets.

A brief word about vector characteristics. Aedes mosquitoes bite both during the day and at night. This means that mosquito bite avoidance techniques must be applied throughout the day and night as mosquitos are prone to bite at any time. Aedes aegypti are able to take multiple blood meals and prefer human hosts. Standing water in tires, flower pots, and refuse can become breeding ground for these mosquitoes who are known to transmit dengue virus, yellow fever and chikungunya in addition to Zika virus. Aedes aegypti prefer urban habitats while Aedes albopictus will live in both urban and rural areas.

To understand prevention, let’s first talk about the incubation period, viremia, and chance of developing Zika virus. The incubation period lasts 3 to 14 days followed by viremia, which lasts a few days to a week. The virus can be shed in multiple body fluids, including semen and urine after viremia has resolved; and viral RNA has been detected in semen as long as 188 days after illness onset. Duration of transmissibility has not been established and, to date, cases of sexual transmission have involved exposure within a few weeks of illness onset.

Recommendations to prevent sexual transmission are points to be reiterated. So again, to prevent transmission from occurring in couples in which a woman is pregnant, we recommend using condoms or abstaining from sex throughout pregnancy. Prevention in couples who are not pregnant and one or both partners have traveled to or live in an area with Zika virus, we recommend couples use male or female condoms or abstain from sex, including vaginal, anal, and oral sex and abstain from sharing sex toys as follows: men for at least 6 months after symptom onset, or last possible exposure if asymptomatic. And women at least 8 weeks after symptom onset, or last possible exposure if asymptomatic.

Because we currently do not have a vaccine to protect travelers from Zika virus infection, mosquito bite avoidance is of the utmost importance. We recommend travelers to areas with Zika virus wear long sleeve shirts, long pants, and closed toe shoes. That they stay and sleep in places with air conditioning when possible and use window and door screens to keep mosquitoes outside. We urge them to take steps to control mosquitoes indoors and outdoors and to use personal protection. We recommend use of EPA registered insect repellents with either DEET, picaridin, IR3535, oil of lemon eucalyptus (OLE), or para-menthane-diol (PMD), and 2-undecanone. It’s important to follow label directions and reapply as appropriate. And OLE and PMD should not be used in children under three years of age. Sunscreen should always be applied before use of insect repellent.

CDC recommends that all travelers protect themselves from mosquito bites for three weeks after leaving a Zika-affected area to prevent the spread of Zika virus in the United States. Three weeks is the time period when Zika virus can be found in the blood, a total of the 2-week incubation period and the 1-week viremic period when Zika virus can be transmitted to others.

Active Zika transmission countries have travel notices posted warning pregnant women to postpone travel to these locations. These countries are currently experiencing outbreaks because of new introduction of Zika virus into an immunologically naïve population where a competent vector is present. The risk to a pregnant woman is high in these settings. In some countries, there’s evidence that Zika virus has existed there for years and the countries may report occasional new cases. A large number of local residents in these countries may be immune, still occasional cases may occur. There’s likely a lower burden of virus within the vector population and a lower force of infection in countries with previously documented Zika virus transmission. Although the risk of getting infected in countries where Zika virus has previously been documented, it’s likely lower than in countries where Zika virus is newly introduced, it’s not zero. Therefore, there’s still a risk that a pregnant woman could get Zika virus and pass it onto her fetus.

We advise clinicians discuss personal risk tolerance with all travelers. As the World Health Organization explains, risk can be assessed by looking at the likelihood of an event on the one hand, and the severity of the consequences on the other. The CDC travel notices will give clinicians an indication of the likelihood of infection, but the acceptance of the possibility of a severe consequence has to be weighed by each individual.

The CDC informs the public of health events that may impact travel using our travel notices. The travel notices include Level 1 watches, Level 2 alerts, and Level 3 warnings. A Level 1 travel notice, or a watch, indicates that a health event is occurring in a destination country the traveler should be aware of. They should be well educated on usual precautions such as being up to date on routine vaccinations, safe food and water precautions, and mosquito avoidance measures; and comply with these recommendations by implementing practices generally recommended for all travelers. Countries where measles and chikungunya outbreaks occur received Level 1 travel notices. There’s no recommendation to go above or beyond usual precautions such as routine measles vaccinations and mosquito bite avoidance measures to the general public or if any population subgroup.

We will post Level 2 travel notices or alerts when we recommend enhanced precautions if you choose to travel to a particular destination or if recommendations differ by population subgroups. Zika and rubella outbreaks have prompted Level 2 travel notices because we give specific recommendations to pregnant women above and beyond usual precautions. Another example of a situation where we post a Level 2 travel notice would be a polio outbreak, where we would recommend a booster dose of inactivated polio vaccine for travelers to that destination. This booster would be recommended in addition to the routine schedule for polio vaccine.

Level 3 travel notices or warnings are posted when we recommend that all travelers avoid nonessential travel to that destination. We posted Level 3 travel notices of Guinea, Liberia and Sierra Leone during the Ebola outbreak and for Haiti in the aftermath of the earthquake.

Countries and territories listed here are those in the Americas where we have current Level 2 travel notices for Zika virus posted. Level 2 travel notices posted because we recommend that a specific population, pregnant women, do not travel to these locations. Because Zika virus is spreading women who are pregnant should not travel to these countries and because Zika virus can also be spread by sex, if the pregnant women has a partner who lives in or has traveled to these countries, we recommend either the use of condoms, abstinence from vaginal, anal and oral sex, and the use of sex toys for the duration of pregnancy.

We advise clinicians to discuss personal risk tolerance with their travelers and recommend that travelers strictly follow steps to prevent mosquito bites during their trip and after their trip. It’s important for providers to ask their patients if they recently traveled and to where, but also if they have plans to travel in the future. Many Americans travel during pregnancy for a variety of reasons including visiting home before the baby is born. We know that travelers who are visiting home countries are at higher risk for malaria and other mosquito-borne illness, and may travel for longer periods of time than other travelers.

Latinos who travel home may visit places with greater exposure to mosquito bites: rural areas, with no screens or air conditioning and areas with less health infrastructure. They may have different health behaviors than tourists, be less likely to visit a doctor before travel, and less likely to follow preventative health precautions. They may not be aware of new health risks in familiar places and may prefer different health information sources in other languages. Clinicians can speak with patients who are from an affected country or if his partner visits an affected country. This includes people who live in the border region and cross into Mexico, for example, in Texas. And in these cases, they and their providers may not consider this travel and not think of their home community or country to be a place that poses a health risk. There’s also clinical guidance for pregnant women living near the US-Mexico border and you can access this on the CDC Zika webpage.

The countries and territories listed here are outside of the Americas and are currently areas of active Zika virus transmission where CDC has Level 2 Zika virus notices posted. We advise women do not travel to these locations- pregnant women do not travel to these locations. There’s no difference between the CDC guidance in these locations than those in the Americas. We also want to reiterate that clinicians can positively impact the health of travelers to all countries by initiating conversations about health risks at their destinations. And these health risks include Zika and specific guidance for certain groups traveling to countries listed here and previously, but also includes safe food and water, road safety, medications and insect avoidance for all of their patients planning to travel abroad.

Travel notices have not been issued for the destinations listed here although the Zika virus has been reported in the past, and travel notices would be considered if the number of cases rises to the level of an outbreak. As we stated earlier, the risk of getting Zika in countries where Zika has been previously reported is likely lower than in countries where Zika is newly introduced. But the risk of Zika to travelers is not zero, and, therefore, there’s still a risk that a pregnant woman could get Zika virus and pass it to her fetus. Because Zika virus infection in pregnant women causes severe birth defects, we advise pregnant women should not travel to areas with active Zika virus transmission. Again, we would urge clinicians to discuss personal risk tolerance with these travelers and, if they decide to travel, to advise that they strictly follow steps to prevent mosquito bites.

CDC maintains a 24/7 consultation service for health officials and healthcare providers caring for pregnant women with suspected or confirmed Zika virus infection. And you can contact the service by phone or email or call 1-800 CDCINFO for other questions. As listed, additional CDC resources here that are available in French and Spanish as well as resources for the traveling public listed here.

I’d like to thank you for your time and attention and the privilege of speaking with you today.

Marcia Friedman: Thank you presenters for providing our COCA audience with such a wealth of information. We will now open up the phone lines for the question and answer session. Joining us for the question and answer session is Dr. Susan Hills. Dr. Hills is a medical epidemiologist in the Division of Vector-Borne Diseases at the CDC. As a reminder, questions are limited to clinicians who would like information related to Zika virus infection. For those who have media questions, please contact CDC media relations at 404-639-3286, or send an email to media@cdc.gov. If you are a patient, once again, please refer your questions to your healthcare provider. When asking a question, please state your organization, and also remember you can submit questions through the webinar system. Operator, do we have any questions on the phone lines please.

Coordinator: We do not have any questions yet.

Marcia Friedman: Okay, looks like we have a question coming in from the webinar system. And that question is: what resources would you recommend for busy clinicians trying to keep up with the CDCs Zika guidance?

Dr. Mary Tanner: I can address that. This is Mary Tanner with the Pregnancy and Birth Defects Task Force. CDC recognizes that there’s a lot of information, and we’re obviously always trying to update that information as new evidence becomes known. So, it can be difficult to really keep up with the flow of guidance and recommendations. So, we really recommend the CDC Zika virus website. There’s a special section for healthcare providers. And with- on that page,- the interactive web algorithm can be a really useful tool too.Kind of follow through a specific clinical question and get the updated guidance there. But I think the best answer to that is just to become familiar with that healthcare provider page of the Zika virus website.

Marcia Friedman: Okay, thank you Dr. Tanner. Operator, do we have any questions coming in from the phones at this time?

Coordinator: We do not.

Marcia Friedman: Okay, looks like we have another question from the webinar and that question is how can clinicians positively impact the health of travelers?

Dr. Allison Taylor Walker: This is Allison Walker from the Travelers’ Health branch of CDC. I’d say there are a few answers to that question and one is by initiating those conversations about previous travel and planned future travel. And then discussing health risks at these destinations which are, again, available on the CDC website at cdc.gov/travel. And these health risks include Zika and specific guidance for certain groups traveling to the countries listed in our presentations, but they also include conversations about risk tolerance and steps to prevent mosquito bites, safe food and water, and all of the other general health topics that are covered in the travel visit. Thank you.

Marcia Friedman: Thanks so much Dr. Walker. Looks like we have another question from the webinar and that is from Liz Estevez. The question is: I remember reading that the guidelines for women had changed from 8 weeks after potential exposure to 6 months same as for men. Did this change again to 8 weeks?

Dr. Mary Tanner: Yes, I can address that. The guidance for women has always been 8 weeks after possible exposure or onset of symptoms. And for men then it is now 6 months after onset of symptoms or last possible exposure.

Marcia Friedman: Okay, thank you. Operator do you have any questions on the phone please?

Coordinator: We do have one that just popped in. One moment.

Marcia Friedman: Thank you.

Coordinator: This question comes from Leslie Crane. Your line is open.

Leslie Crane: Yes, Leslie Crane and have the slides been sent out or do we just need to go on the site because there are a lot of good information I want to pass onto our clinics, our OB-GYNs and our ED.

Marcia Friedman: Hi, yes this Marcy Friedman. The slides are available on our COCA website and the web address is emergency.cdc.gov/coca.

Leslie Crane: Okay.

Marcia Friedman: You’ll see the slide set located there and also within the next few days there will be call transcript as well that will be uploaded to the site as well. So, you can refer folks there.

Leslie Crane: Thank you, because it’s really great and I appreciate your information.

Marcia Friedman: Thank you so much. We appreciate you listening in. Okay, it looks like we have another question that came in from the webinar. The question is what is the latest information on available vaccines?

Dr. Susan Hills: This is Susan Hills. I can perhaps answer that question. So, there are multiple vaccine candidates that are in development at the moment, and they’re all in different stages of development. Some are pre-clinical, some are Phase 1, in Phase 1 trials and moving into Phase 2 trials. What we need to remember is that although there are efforts to speed development and availability of the vaccine, there are a lot of steps that need to go through, that need to be completed to have a vaccine available. And even simple things like choosing an appropriate site to be able to test the vaccine and get meaningful results can be a time-consuming process. So, we certainly are unlikely to see any vaccines available before 2018 and the, of course, the question would be how best to use those vaccines in terms of the strategy for who to vaccinate. So, all of that is clearly something that’s going to be under discussion over the next one to two years.

Marcia Friedman: Thank you so much, Dr. [Hills] And operator do we have any other questions on the phone lines please?

Coordinator: We do. We have a question from Dr. Warner Hudson. Your line is open.

Dr. Warner Hudson: Hi, thank you. There was a recent letter to the editor in the New England Journal on a Spanish woman who developed Zika when she was pregnant. And her blood test for Zika stayed positive for 89 days and her RT-PCR positive for 107 days after symptom onset. I guess, that may cause some to wonder if 8 weeks is long enough. Any comments on considerations at CDC of editing the 8 weeks for women current party line? Thanks.

Dr. Mary Tanner: Thanks for that question. You know at this time we think that this prolonged viremic presentation may be unique to pregnancy. So, we continue to look at available information as it comes in and reevaluate those recommendations on an ongoing basis. But right now, the recommendation stands with the eight weeks.

Dr. Warner Hudson: Thank you.

Marcia Friedman: Okay, thank you and operator, do we have any other questions from the phone please?

Coordinator: We do not at this time.

Marcia Friedman: Okay, remember dialing star 1 will put you in the queue for a question and we’ll wait just for a few seconds for anybody who may have missed that dialing Star 1 will allow you to ask a question. Okay, it looks like we are all finished with questions.

On behalf of COCA, I would like to thank everyone for joining us today with a special thank you to our presenters Drs. Tanner, Taylor Walker and for Dr. Susan Hills for joining us for the Q&A portion of the call. The recording of this call and the transcript will be provided to the COCA website at emergency.cdc.gov/coca within the next few days. All continuing education for COCA calls are issued online through TCE Online, the CDC Training and Continuing Education Online system at www.cdc.gov/tceonline. Those who participated in today’s COCA Call and would like to receive continuing education, should complete the online evaluation by January 9, 2017, and use course code WC2286. Those who will review the call on demand and would like to receive continuing education, should complete the online evaluation between January 9, 2017, and December 7, 2018. And also, use course code WD2286.

To receive information on upcoming COCA calls, subscribe to COCA by going to the COCA webpage at emergency.cdc.gov/coca and clicking on the join the COCA mailing list link. Please join us for our next COCA Call on Tuesday, December 13 where the topic will be “Effectively Communicating With Patients About Opioid Therapy.” Also, you’re invited to like our Facebook page at Facebook.com/CDCClinicianOutreachAndCommunicationActivity to stay connected to learn the latest news from COCA. Thank you so much, again, for your time and for being part of today’s COCA Call. Have a great day, thank you.

Coordinator: Thank you. That concludes today’s conference. Thank you for participating. You may now disconnect.

END